Provider Demographics
NPI:1518662287
Name:PARKS, MICAIAH (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:MICAIAH
Middle Name:
Last Name:PARKS
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 LLANO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5412
Mailing Address - Country:US
Mailing Address - Phone:505-920-6860
Mailing Address - Fax:
Practice Address - Street 1:1720 LLANO ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5412
Practice Address - Country:US
Practice Address - Phone:505-920-6860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM374970163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool